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Advances in Psychiatric
Treatment
Treating depression in substance misuse
APT (2001),
vol. 7, p.(2001),
357 vol. 7, pp. 357–364
Treating depression complicated
by substance misuse
Claire McIntosh and Bruce Ritson
Dependence on alcohol or other drugs is a depressing experience. The way of life of the individual
who is dependent on alcohol is replete with
incidents that are demoralising, waking daily with
a hangover or with tremor and retching, coupled
with amnesia for events of the night before, a sense
of inability to face the day ahead and awareness of
recriminations at work and at home. Little wonder
that depressed mood is common in such circumstances. Similarly, the drug addict, when life is
dominated by the daily problem of obtaining
supplies of a substance that brings transient relief
or pleasure but also experiences of an impoverished
existence and low mood. Add to this the fact that
the biological action of many commonly misused
substances can induce depression then it is hardly
surprising that depression is common in this
population. There are also a smaller number who
use alcohol or illicit drugs to cope with primary
depression. Teasing out the interplay of affect and
substance misuse is a challenge for the general
psychiatrist and the addiction specialist.
As many as 80% of alcoholics complain of
depressive symptoms, including 30% who fulfil
criteria for a major depressive disorder (Raimo &
Schuckit, 1998). A lifetime history of depressive
disorder has been found in 48% of opiate addicts
(Rounsaville et al, 2001). Thus, it is clear that
substance misuse and depressive symptoms often
occur together, but what is less clear is their true
relationship. Box 1 shows three frequently asked
questions concerning it.
The combination of depressive symptoms and
substance misuse presents important management
issues, both at the level of the individual patient
and regarding service provision. In individual
patients it is often difficult to disentangle all threads
of the presentation. An unusual mental state may
be due to intoxication, and substance misuse may
be hidden. A frequent management dilemma is the
intoxicated patient in the middle of the night, who
has self -harmed, or is threatening to do so.
Although depressive symptoms and substance
misuse commonly occur together, services for their
joint management do so less frequently; a recent
editorial talks of the “medical model of psychiatric
services […] contrasting sharply with the psychosocial orientation of substance misuse services”
(Weaver et al, 1999). In the UK patients with
depression are cared for by generic psychiatric
services and substance misusing patients by drug
and alcohol services, with few examples of dual
diagnosis services evident. We should, however,
remember that no similar distinction exists in
Box 1 The relationship between substance
misuse and depression
Three frequently asked questions
Are the depressive symptoms and disorders
caused by the substance misuse?
Do depressive illnesses cause people to selfmedicate with alcohol and drugs?
Are there common predisposing factors
linking the two presentations that account
for their frequent co-occurrence?
Claire McIntosh is a specialist registrar in substance misuse and general psychiatry training working with the Substance Misuse
Directorate of the Royal Edinburgh Hospital. Bruce Ritson is a consultant in the Alcohol Problems Service and senior lecturer
at the Department of Psychiatry at Edinburgh University (Royal Edinburgh Hospital, Morningside Terrace, Edinburgh EH10
5HT). He is a former chairman of the Addiction Faculty of the Royal College of Psychiatrists. His research interests are in
treatment evaluation and the development of community response to alcohol problems.
APT (2001), vol. 7, p. 358
primary health care and that the general practitioner
has a key role in which route is taken by the patient.
It is also known that the majority in both categories
do not come to specialist services. None the less,
having more than one psychiatric diagnosis leads
to an increased likelihood of presentation to
treatment services (Wu et al, 1999), but there are
rarely skilled appropriate services available, able to
offer a multifaceted approach to care.
Epidemiology
The scale of the co-occurrence of the diagnoses of
depression and drug and alcohol misuse has been
examined by a number of large population-based
studies.
The largest of these is the Epidemiologic Catchment Area (ECA) study (Regier et al, 1990). This
showed that of people with an alcohol disorder, 13%
met criteria for an affective disorder. More strikingly,
32% of those with affective disorder met criteria for
a substance misuse disorder. Other studies support
these figures and suggest higher correlations (Farrell
et al, 1998; Kessler et al, 2001).
As would be expected, studies looking at groups
of people in contact with treatment services give an
even higher estimate of the co-occurrence of
depression and substance misuse (Rounsaville et
al, 1982).
There is also a body of work looking at suicide in
this group; in fact, the most common mental
disorders preceding suicide have consistently been
found to be depressive illness and alcohol misuse.
Comorbidity is more common in alcoholics who
commit suicide than in alcoholics who do not commit
suicide, and has been found to predict suicide risk
(Driessen et al, 1998). Interestingly, severity of
alcoholism seems not to be of importance (Berglund
& Ojehagen, 1998). The extent to which substance
misuse increases the likelihood of a fatal outcome
also needs to be taken into account: drug overdoses
are frequently taken in association with large
quantities of alcohol.
The likelihood of suicide in conservatively
diagnosed alcoholics has variously been estimated
at between 60 to 120 times that for those without
psychiatric illness. A number of life stressors have
also been implicated, including interpersonal loss
and conflict, which have been found more often in
the 6 weeks preceding death in those suicides
associated with substance misuse. Other associations include an increased likelihood of parental
alcoholism and a younger age at which problem
drinking started (Berglund & Ojehagen, 1998).
McIntosh & Ritson
A strong predictor of completed suicide is previous
self-harm. A consistent finding has been that suicide
attempters who misuse alcohol have higher rates of
substance misuse and depression, multiple psychiatric disorders and more encounters with lawenforcement agencies (Berglund & Ojehagen, 1998).
In drug misusers there is also a high excess mortality
from suicide. Prevalence rates of attempted suicide
have been reported ranging from 15 to 45% (Rossow
& Lauritzen, 2001).
Substance misuse and
depressive symptoms
Are depressive symptoms and
disorders caused by substance
misuse?
Alcohol intoxication can be accompanied by
temporary but severe depressive symptoms. Longterm alcohol use is also associated with depressed
mood, and almost all alcoholics report periods of
intense sadness. A categorisation of the presentations of alcohol-associated mood disorders is given
in Box 2. This suggests that substance-induced
disorders are commonly phenomenologically
indistinguishable from independent major depressive disorders. However, they will remit 2–4 weeks
after alcohol drinking has ceased, without the need
for antidepressants. At presentation to an alcohol
treatment programme, 42% of alcoholic men had
significant depressive symptoms, but only 6% were
clinically depressed after 4 weeks of abstinence
(Brown & Schuckit, 1998).
Box 2 Presentations of alcohol-associated
mood disorders (Raimo & Schuckit, 1998)
Patients with alcohol-related mood disorders
may be categorised as
Those with a primary substance-induced
disorder and secondary depressive
symptoms
Those with underlying physical disorders,
such as liver disease or medication effects
(e.g. treatment with anti-hypertensives),
who are remediable by treatment of the
underlying disorder
Those with an independent major depressive
disorder
Treating depression in substance misuse
In support of the validity of this distinct subcategory, Brown & Schuckit give the following
evidence: both alcoholism and depression are highly
familial disorders, but children of alcoholics,
although showing increased problems with substance misuse, do not show an increased incidence
of independent mood disorders, as would be
expected if all depressive symptoms were attributable to independent mood disorder. Work looking
at longitudinal follow-ups of adults who had had
teenage depression demonstrated no increased
incidence of alcohol dependence compared with
controls. A longer-term follow up of alcoholic men
also showed that with sobriety, the incidence of
depression was similar to other men (Raimo &
Schuckit, 1998). It is from such work looking at the
differences in presentations over time that the
concept of substance-induced depressive disorder
came to be formulated.
Although the majority of work done has related
alcohol and mood, other substances also have
important mood effects. Amphetamine and cocaine
may have dramatic intoxication presentations,
including mood disturbance, which have been well
documented. Post-intoxication effects, particularly
depression, should also be borne in mind with these
drugs, as they can be more devastating than acute
effects. Depressed mood following the use of ecstasy
(3.4–methylenedioxymethamfetamine) is frequently
described and sometimes severe.
Long-term studies have looked at depressive
symptoms in opiate addicts. Overall, depressive
symptoms were found to be common, particularly
at presentation to services, but were generally in the
mild to moderate category. The reasons prompting
the contact, such as child custody or criminal justice
involvement, may also lead to lowering of mood.
During contact with drug treatment services
substantial improvement occurred, with little
difference between drug-free and methadonemaintained groups. Only 1% of this patient group
required antidepressant treatment, showing that
stabilisation of drug use and detoxification can have
beneficial effects on the mood state, without formal
treatment for depression (Rounsaville et al, 2001).
Do depressive illnesses cause
people to self-medicate with
alcohol and drugs?
It is very difficult to design studies to answer this
question. A search for plausible explanations is a
universal human characteristic, and patients
seeking treatment will inevitably be involved in a
search for cause and explanation, thus biasing their
APT (2001), vol. 7, p. 359
recall. A key concept in this field is the ‘selfmedication hypothesis’, the proposal that people
with psychiatric symptoms are motivated to take
alcohol or drugs to relieve their symptoms. Patients
will often report that they drink or take drugs to
alleviate stress or to help depressed feelings.
One review (Chick, 1999) quotes a prospective
population study (Moscato et al, 1998). This showed
that in females, depressive symptoms predicted
alcohol misuse at 3 and 4 years, but not at 7 years.
There was no effect for men. This suggests that, for
women, depression may predate alcohol misuse.
Prospective studies have also found that a diagnosis
of major depression at entry to in-patient treatment
predicted a shorter time to first drink (Greenfield et
al, 1998).
Stimulants such as cocaine or amphetamines
produce a transitory lifting of mood but with
rebound depression. Alcohol relieves anxiety and
gives some blunting of concern about depressing
circumstances, but these effects are short lived. There
are, however, no indications for the positive effects
of alcohol in psychiatric disorder, and any effect
may be explained more by positive expectations
from alcohol than by any true effect (Berglund &
Ojehagen, 1998). Indeed, the detrimental effect of
alcohol and drug misuse on symptomatology is
much more common.
Are there common predisposing
factors linking the two
presentations that account for
their frequent co-occurrence?
An alternative way of viewing these disorders is
that there are factors, either genetic or environmental,
that independently cause both conditions. Several
genes involved in serotonin metabolism have been
implicated in both depression and alcohol dependence. Research using twin studies has also been
initially supportive of this hypothesis, although
further studies are needed (Chick, 1999).
Recognition of comorbidity
As already stated, substance misuse has a key role
in the genesis of symptoms and has also been shown
to worsen prognosis in mood disorders (Berglund
& Ojehagen, 1998). It is therefore important to seek
out its occurrence, especially in frequent users of
psychiatric services, who have been found to be
particularly at risk (Scott et al, 1998).
APT (2001), vol. 7, p. 360
Assessment
The assessment process should ensure that mental
health service staff can reliably detect alcohol and
drug misuse and that addiction services can detect
depressed mood. Ideally, both services should use
similar guidelines for identifying and recording this
information.
Nearly half of 15- and 16-year-olds in the UK
report illicit drug use (Miller & Plant, 1996). Because
these drugs may be relevant to the patient’s mood, a
history of drug use is an essential part of the initial
examination. This should be backed up by urine
testing for drugs in cases where suspicion is aroused.
Many commonly misused substances are eliminated
from the body within 24–48 hours; therefore, if testing for toxicology is required, samples should be taken
early after admission or at the time of first contact.
The close links between alcohol misuse and mood
disturbance make it essential that a drinking history
is taken in every case. It is still not uncommon to
find psychiatric case records where there is no
description of the patient’s drinking pattern or it is
given in a very cursory way, for example “drinks
socially” or “moderate drinker”. What is required
is a brief but clear picture of the patient’s drinking
habits. This can be achieved in a variety of ways;
one of the simplest is to ask on how many days a
week the patient normally has a drink of alcohol,
and how much is typically drunk on those days.
Calculate the answer in units and you have a rough
estimate of that patient’s weekly consumption. This
information is augmented by asking whether alcohol
has caused any problems.
There are a variety of screening tests for alcohol
use, including the CAGE questionnaire (Mayfield et
al, 1974), which reliably identifies drinkers with
problems but often misses ‘at-risk drinkers’. The
latter are detected by the broader Alcohol Use
Disorders Identification Test (AUDIT) questionnaire
(Babor et al, 1989). Both of these are slightly more
time consuming than very brief tests such as the
Paddington Alcohol Test (Smith et al, 1996),
developed for accident and emergency settings.
These tests can be augmented by blood markers such
as gamma-glutamyl transferase (GGT), mean
corpuscular volume (MCV) and carbohydratedeficient transferrin (CDT). These biological
measures can also be used as a guide to progress.
Feedback concerning abnormal blood results can
be powerful objective evidence demonstrating to the
patient that alcohol is causing damage, an appreciation that is reinforced by signs that these figures
gradually improve once drinking ceases.
The assessment interview should provide a clear
picture of the level of current substance misuse, the
McIntosh & Ritson
amount taken on a daily basis, the pattern of use
and the route of administration. Evidence of selfharm, violence to others, disturbed thoughts or
moods, and their relationship to substance use
should be noted. Assessment of mood should
enquire into biological symptoms of depression, the
duration of the depression and its particular relation
to substance misuse.
The screening instruments for alcohol and drug
use and those concerned with affective disorder
have not been tested in patients with dual diagnosis.
The influence of one condition on the other may give
rise to misleading results; for example, many of the
features of biological depression are mimicked by
the consequences of repetitive excessive drinking,
such as feeling ill and depressed in the morning,
being unable to face the day, weight loss, impaired
concentration and memory and insomnia.
Depression is probably overdiagnosed in individuals with alcohol problems, as it often proves to be
secondary to the drinking problem itself. A wrong
diagnosis of depression may give rise to unnecessary prescribing of drugs or even electroconvulsive
therapy. However, on some occasions, an underlying
depressive disorder is missed. The lifetime risk of
suicide is very much higher in problem drinkers than
in the general population, and this risk is increased
by the presence of a depressive illness.
Even at the stage of assessment it can be useful to
include components of motivational interviewing
(Miller & Rollnick, 1991) and to forge links in the
patients mind between increased substance misuse
and worsening of symptoms. At assessment it is
also important to create an open, non-judgemental
attitude to try encourage frankness about substance
misuse.
If the patient is intoxicated it may be very difficult
to obtain any form of coherent history. In these
circumstances the importance of a collateral history
cannot be overstated. In an ideal world a safe
environment would be available, in which the
patient could remain until the effects of intoxication
have resolved, leaving a clearer assessment of mental
state. Unfortunately, this is not always possible
owing to lack of resources. Even an assessment on
the following day is not always straightforward, as
withdrawal symptoms are not without their own
powerful influences.
Management
Safety is of prime importance in the management of
this group. In addition to the increased risks of selfharm, the disinhibiting effects of many substances,
Treating depression in substance misuse
particularly alcohol, should be carefully considered.
Within psychiatry, there prevails a culture of
ignoring the threats of intoxicated patients, even
though they are sometimes carried out. A risk
assessment should be made of each individual
patient’s circumstances.
Pharmacological management
At initial presentation it will be very difficult to
differentiate independent mood disorders from those
due to continued substance misuse. A key message
in all the literature in this area is the importance of
treating the substance misuse, and the highly
probable beneficial effects that this will have on the
mood state.
Alcohol detoxification has been discussed in a
previous paper in APT (Raistrick, 2000), which
recommends a period free from psychoactive drugs
prior to starting treatment for depression. A wait of
2–4 weeks post alcohol cessation is advised before
commencing antidepressant treatment, to ensure
that the mood effects of the alcohol have cleared the
system (Raimo & Schuckit, 1998).
With opiate misuse, a primary aim of treatment
may be stabilisation and substitute prescribing, not
detoxification. This in itself has been shown to have
a beneficial effect on mood (Rounsaville et al, 2001).
In the past, antidepressants were considered as
treatments for alcohol misuse in people without
depressive symptoms. Current opinion does not
support this. However, in an in-patient sample,
detoxified patients with depression randomly
allocated to fluoxetine or placebo showed that the
active drug helped to reduce depressive symptoms
(Cornelius et al, 1997). Other studies do not support
this result, and work continues to clarify the benefits
of antidepressants within alcoholic subtypes
(Pettinati et al, 2000).
In one study, Mason et al (1996) found that
desipramine reduced depressive symptoms and was
associated with significantly longer abstinence from
alcohol. However, they concluded that there was no
support for desipramine in alcoholics without
depression. In a review of this topic, Lynskey (1998)
concludes that antidepressant treatment is not a
standalone treatment for alcoholics with depression,
but that pharmacological treatment of depression
may help to optimise the outcome of treatment for
alcohol dependence in this group. The same paper
also raises the important question of drug safety in
this group.
Darke & Ross (2001) studied the safety of the use
of antidepressants among injecting drug users in
Australia. They reported a strong association
between antidepressants and non-fatal heroin
APT (2001), vol. 7, p. 361
overdose. The use of tricyclics was particularly
hazardous. They recommended the use of selective
serontonin reuptake inhibitors (SSRIs), but only
where clearly indicated. They commented on the
street value of antidepressants, noting that opiate
misusers took them for a variety of reasons: to selfmedicate depressive symptoms, to become intoxicated, to aid sleep and to manage heroin withdrawal.
A further consideration is that methadone slows
tricyclic metabolism, so tricyclic dosing must be
carefully titrated.
There are few studies examining the positive
effects of antidepressant use among drug misusers.
Randomised controlled trials have been difficult to
complete owing to high dropout rates. There are
mixed reports of efficacy, with some positive results
reported (Scott et al, 1998). A study looking at
fluoxetine concluded that it was not effective in
treating depressive symptoms in methadonemaintained opiate addicts, but commented that there
were significant overall reductions in depression
while patients were in contact with drug treatment
services (Petrakis et al, 2001).
A variety of pharmacotherapies are available in
the treatment of alcohol problems. Disulfiram is a
useful aid to abstinence of proven effectiveness when
combined with supervision. In a small number of
cases, psychotic episodes have been described as a
side-effect of disulfiram, but in most respects it is
safe to use. Unfortunately, it can have serious
consequences if misused, and particular care should
be taken in prescribing it to patients with depression
who may be suicidal. Acamprosate and naltrexone
have both produced improved outcomes in individuals who are alcohol dependent. We do not know
about their efficacy in patients with dual diagnosis,
but it seems reasonable to use one or the other when
patients are particularly conscious of craving during
the early months of abstinence. Either can be
combined with antidepressants, if necessary.
Psychological therapies
Psychological therapies must be considered both in
their own right and in combination with medication.
There is a growing literature in this area, although
most work has centred on motivational interviewing
(Miller & Rollnick, 1991), which can be a useful
technique throughout assessment and treatment.
Trials of cognitive therapy have shown promising
results that mirror antidepressant findings: an
improvement in depressive symptoms can lead to
an improvement in substance misuse (Lynskey,
1998). There has also been promising work
APT (2001), vol. 7, p. 362
incorporating facets of cognitive therapy and early
work on interpersonal therapy (IPT; Scott et al, 1998).
Miller et al (1998) reviewed the literature on the
treatment of alcohol misuse, deriving a methodological quality score; they listed a number of
positive and negative results for each and gave a
clinical effectiveness score for those methods that
had been adequately investigated. Motivational
enhancement showed consistent benefits, as did
community reinforcement, acamprosate, naltrexone
and social skills training. Again, it is not clear how
well these approaches combine with other treatments for depression. None the less, it seems
reasonable to think that that these psychological
therapies for alcohol problems should be added to
traditional therapies for depression.
Treatment for substance misuse commonly relies
heavily on the motivation or commitment of the
patient. Bien et al (1993) outlined the key features of
brief intervention as feedback about current misuse,
the patient’s own responsibility for change and
advice about making and maintaining this change.
Therapy for substance misuse, and particularly
alcohol dependence, places much greater responsibility for change on the patient and there is less
reliance on a medical model. Patients with severe
depression may find it hard to engage in this kind
of therapy until their mood has lifted.
Although group therapy now has a less salient
place in the treatment of alcohol problems than
formerly, it is still widely used. Patients with
depression may find group processes very threatening and require careful introduction, after severe
depression has lifted. Alcoholics Anonymous (AA)
and Narcotics Anonymous are very effective selfhelp agencies but, again, individuals who are
depressed may find it difficult to join them because
they anticipate that the experience will be threatening. The first steps can often be made easier by
introduction to an empathic member before attending the first meeting.
The risks of the interaction of antidepressant
medication with alcohol and illicit drugs, and the
associated special hazards of medication overdose
and misuse, make psychological therapies an
attractive proposition either as an alternative or
additional treatment.
McIntosh & Ritson
alcohol dependence predicted a shorter time to
first drink and relapse in both men and women
(Greenfield et al, 1998). Similarly, among patients
addicted to opiates, a current major or minor
depressive episode at entry to treatment was
correlated with higher levels of illicit drug use
during the subsequent 6-month period (Rounsaville
et al, 2001). The large increase in risk for attempted
and completed self-harm implicit in a diagnosis of
comorbidity has been described above.
Service provision
Often, patients with two diagnoses fall between
services designed to treat either the depression or
the substance misuse. The creation of ‘superspecialist’ services has been advocated, particularly
in the USA, but UK services have suggested other
strategies to try to improve practice. In a number of
centres, combined psychosis and substance misuse
teams have been created to treat patients with dual
diagnosis and act as a consultancy and training
resource for other agencies. These initiatives will be
watched with interest.
There have been calls for improved staff training,
both in mental health and addiction services, to try
to improve recognition of comorbidity. Increased
sharing of skills and support between the two
services has also been recommended (Hall & Farrell,
1997). It is often helpful for staff in one agency to
gain experience in the other, as this helps mutual
understanding and knowledge of the issues
involved. It has also been stated that services for
drug misuse and mental health have tended to
develop in ways determined more by public anxiety
and political ideology than by research evidence.
Training an appropriate workforce, research into the
efficacy of services and the development and testing
of new models of service provision are required
(Weaver et al, 1999 ). Box 3 lists the attributes that
should be present if both services are to achieve
optimum efficacy.
Summary
Prognosis
Comorbidity carries with it a worse prognosis, both
for substance misuse and depressive symptoms
(Hall & Farrell, 1997). A diagnosis of current major
depression at entry into in-patient treatment for
Patients presenting with depression complicated by
substance misuse pose particular challenges in their
management. Their depressive symptoms are very
likely to be caused or exacerbated by their substance
misuse. In alcohol misuse, a 1-month period
of abstinence and then further evaluation are
Treating depression in substance misuse
Box 3 Requirements of services to ensure
optimal treatment of depression in substance misuse
Psychiatric services
Individuals who misuse substances must
have the same right to treatment as other
patients
A substance-use history must be recorded in
all cases
Clear protocols should be in place to ensure
treatment and follow-up when misuse is
identified
Regular liaison with addiction services and
knowledge of services available are
essential
Care plans should identify a strategy for
dealing with substance misuse
The implications of drug interactions between prescribed medication and alcohol
or illicit drugs must be considered
Addiction services
The attitude that mental illness excludes
patients from effective therapy must not
be allowed
Mood and suicidality must be assessed and
monitored
If mood disorder persists after 2 weeks of
abstinence or stabilisation, a diagnosis of
depressive illness should be considered
Regular liaison with general psychiatric
services is essential
Follow-up plans should include regular
mental state assessments
recommended before the commencement of pharmacotherapy. Opiate users should be stabilised
before pharmacotherapy. Prescription of antidepressants must be very carefully considered, as they
have a street value and might therefore be widely
disseminated; also, there is little evidence supporting their efficacy in treating depressive symptoms
in this group. SSRIs would be the treatment of choice.
Strong consideration should be given to psychological therapies such as motivational interviewing
and cognitive–behavioural therapy, which are
currently being further evaluated and hopefully
should become more available to patients with
comorbidity. Equally, treatment of depressive
symptoms also yields benefit in managing substance
misuse, with antidepressant treatment decreasing
alcohol intake in alcoholics with depression.
APT (2001), vol. 7, p. 363
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Multiple choice questions
1. Regarding the epidemiology of substance misuse
and depressive disorders:
a. in the ECA study, 32% of those with affective
disorder met criteria for an alcohol disorder
b. the likelihood of suicide in alcoholics has been
estimated at 120 times that of those without
psychiatric illness
c. in the ECA study, 31% of those with an alcohol
disorder met criteria for an affective disorder
d. a long-term follow-up of alcoholic men showed
that, with sobriety, their incidence of
depression was equal to that of other men
e. teenagers with depression show an increased
incidence of alcohol misuse in later life.
2. Regarding self-harm in substance-misusing
populations:
a. comorbidity predicts suicide risk
b. interpersonal loss is unimportant
c. parental alcoholism has been found to be
associated
d. alcoholics who have no diagnosis of
depression do not self-harm
e. in drug misusers deaths attributed to
accidental overdose may be suicides.
McIntosh & Ritson
3. Antidepressants:
a. are unhelpful in the treatment of alcohol
misuse
b. are contraindicated in methadone-maintained
populations
c. have been implicated in opiate overdose
d. may decrease substance misuse
e. have a street value.
4. Regarding the treatment of depression in substance misusers:
a. assessment of an intoxicated patient is without
value
b. IPT and CBT may prove beneficial to both
depressive and substance-misuse symptoms
c. contact with treatment services may prove
more beneficial to mood than antidepressants
d. depressive symptoms may be predictive of
earlier relapse
e. abstinence will improve mood in the majority
of cases.
5. True or false:
a. motivational interviewing is solely for use in
substance misuse
b. comorbidity increases the chance of
presentation to treatment services
c. comorbidity services are always evidence
based
d. methadone has antidepressant properties
e. children of alcoholics have high rates of
depressive disorders.
MCQ answers
1
a
b
c
d
e
T
T
F
T
F
2
a
b
c
d
e
T
F
T
F
T
3
a
b
c
d
e
F
F
T
T
T
4
a
b
c
d
e
F
T
T
T
T
5
a
b
c
d
e
F
T
F
F
F